Excerpt: Eating Pomegranates: A memoir of mothers, daughters and the breast cancer gene

Best HealthOctober 5, 2009

Journalist Sarah Gabriel was diagnosed with breast cancer at age 44'a result of a rare inherited mutation on the BRCA1 gene. Get a glimpse at her story through this excerpt from her new book

Source: Web exclusive: October 2009

On the EveIt’s 13 March 2006. I am propped up on the sofa with a pink leaflet about how to perform breast self-examination open on my chest and a glass of Chardonnay by my side. R (husband) is at the other end of the sofa, watching Manchester City play Tottenham Hotspur on the TV.

Strictly speaking, R does not like Chardonnay. He says it is a ‘nasty’ drink, laden with chemicals that thicken his head in the morning. But he keeps me company loyally. Has done for many years.

His mother’s drinking has always been a problem for R. So he drinks to limit me to my half of the bottle, in case I go the same way. As a result, at times he has had a half-a-bottle-of-Chardonnay-a-day habit. When he goes to visit his mother, it’s worse. Whisky. Maybe if he keeps pace with her, is true to her in the place she has to go to, she won’t have to go there. Maybe she will turn about and focus the mother’s mirroring gaze on him. My darling child, how could I desert you? And for what, after all? A mess of toxins at the bottom of a bottle.

It never works. He never stops. He is the wandering knight to her Belle Dame Sans Merci. So a psyche is born.

‘It says here you draw the hand in concentric circles outward to the perimeter of the breast and then bring it back again in radial lines.’

I am reading aloud to distract myself. Everything from the nasty salmon-pink colour of the leaflet, a standard-issue Pantone number favoured by government departments and the NHS, to the brutal anatomical diagrams, and the remote possibility of finding something, combines to make this task distasteful.

‘What do you think it means by . . . ?’ I am confused by a description of a dimpling of the skin that can occur when a lump is pulling at it from within. Examining the smooth, clean skin of my breasts, I see nothing. But maybe I just don’t know how to look?

‘Mmmn?’ says R, without focusing. He is concentrating hard to follow the commentary on the game, which is turned to low volume. This is our compromise. Chardonnay for football. Low volume for public breast examination. The continual trade of marital relations.

‘What do you think it means . . . ?’ If he had a page in front of him, with a patch of sunlight on it, and I were a cat, I would leap lightly across and curl myself up to get his attention.

But the Spurs striker has just done a header that clipped the goalpost. There is the collective gasp, a sotto voce roar, of male disappointment. A crash of testosterone up and down the country, which R, throwing himself back on the sofa in our narrow living room, echoes loyally. ‘Idiot!’

I turn back to the diagram with a sigh. Confronting me, in fuzzy black-and-white print, is a semicircle standing on its tip. It looks like a protractor, or a rubber drain plunger perhaps. Inside it, a tangled mass of black lines converge angrily on a knob at the end. These are the ducts. In any one of these ducts, I am told, designed to carry milk from the fatty tissue to the nipple in response to the baby’s sucking motion, a lump might form. Struggling to map this bleak geometry on to the living body, I finger my breast desultorily, unsure how to distinguish its naturally grainy texture from anything more sinister.

Writing this, I am aware that this woman has something childish about her. Dishonest, even. She should be upstairs, in front of a mirror, without a glass of wine, doing the job properly.

Embarrassing. The instinct is to move on. So instead we’ll do the opposite, and move in closer. Lean over on creaking knees and take a little look. What is going on there? There is a picture of myself at thirteen. The bedroom of a large manse in Scotland, a little chilly, windows open on to a view of hills. I have a few drops of bright blood between my legs. I found them earlier, in the toilet, freshly staining the skin. I am frightened. I have managed to tell my mother. This was not easy. She had five children and was often unavailable.

My mother appears. She is carrying a contraption made of white pads and cotton ropes. I have no idea where she got it, whether it is one of her own, or whether she had it in waiting for this moment. It looks like a kind of harness for the bottom half of the body. The packet it has emerged from is called ‘Dr White’s’. I remember the dirty pink and turquoise colours of the wrapping, aimed to capture femininity and hygiene, and somehow soiling both. ‘You have your periods now. You need to wear this,’ says my mother. Then she turns to go. ‘But how?’ I manage to get out, the contraption dangling from my horrified hand. Her voice accelerates; seems to become more chilly. ‘The girdle goes round the waist, the pad down below. It’s perfectly simple. You’ll work it out.’ And she is gone. There is supper to cook, the washing to put out, the dogs to walk, the little ones to take care of.

The next image is a scuffed green prefab building, 1970. Primary Seven, the last year before secondary school. We are gathered to hear a lecture by head teacher Mrs Cormack on ‘The Facts of Life’. Diagrams are pinned to the blackboard, showing a man’s penis, the insinuating twin-bean shape of the ovaries connected by the pendulous ‘u’ of the fallopian tubes. I have seen these shapes for years inscribed on toilet walls and bus shelters. To see them posted up on a blackboard in this way seems obscene. A calculated affront.

Mrs Cormack explains that to make a baby, the man’s penis is inserted in the woman’s vagina. This releases something called ‘sperm’. The sperm fertilises the egg, which is implanted in the lining of the womb and fed via the umbilical cord with nutrient-rich blood from the mother. ‘If you have any questions about this process, please feel free to ask. You may do so confidentially.’ She invites us to write our questions anonymously on pieces of paper and put them in a basket. ‘Can you have a baby without the man’ s penis going inside the woman’s vagina?’ I write solemnly, folding my little note many times. At the front, I watch her unfold it and frown. ‘This class was set up for serious matters,’ she says, tossing it aside. ‘If anyone is going to turn it into a joke, I’ll put a stop to it immediately.’

Later, the consequences of this self-hatred, the internalised phobia of the feminine. A yo-yo pattern of binge-eating and dieting. No, Mother, I will not become you however hard you try to fill me full of the food that will turn me into you. I will stopper up my mouth. Your cooking, which you so poignantly love (God knows why; how can it rescue you?), is a poison that I am determined to vomit up. I shall defy you, refuse to grow belly, thighs, breasts. If you force the issue, I shall refuse to grow at all. I will not be destroyed by pregnancy after pregnancy until I am tired and broken and old beyond my years. I will not surrender myself to the tyranny of the male will. To be granted only half a place at the hearth. To be forced to offer cups of tea, meals, compliance, concession, admiration, desperation, anything to buy off the outpourings of male frustration and discontent.

And I shall not die. Suddenly and catastrophically at forty-two. Leaving five children and a husband behind.

So perhaps it’s not surprising that I am unable to examine my breasts properly. Childish? Yes, certainly. Until my dead mother walks back into the bedroom, kneels before me, and talks me tenderly through how to put on that contraption, with her eyes resting calmly on mine, her voice kind and measured, how am I to grow up? Half-made woman? Yes, certainly. I may be forty-four. I may have children now myself. But I am still waiting. Didn’t Orpheus look back for his Eurydice though it was mortal folly? Didn’t Persephone eat the pomegranate pips though it condemned her in per petuity to six months of every year in the underworld? For how long did Hades have to press them on her before she ate? And what did those sweet seeds taste like? Did they carry the bitterness of his kingdom? Or did they taste of the great green upper world, and the tumult of her mother’s longing for her daughter? Isn’t mitosis ‘ self-division ‘ at the very heart of things?

‘R, I think I might have found something.’

‘Mmmn?’

‘Really, R, I think I might have.’

‘Wait a minute,’ he says, attention focused on the screen, where someone is gearing up to take a penalty.

My first reaction is simple curiosity. Examining my left breast, as instructed, with half a mind charting the strategy of the match and the emotional barometer of R’s masculinity, my finger rolls over a lump. At first it feels like nothing, or rather something so insignificant the mind scarcely registers it. You are crossing a level terrain. All around you the smooth and even surface stretches out. But you come off a tiny shelf. It is so shallow, there is no disruption whatsoever to your feet, which carry you evenly onward. It’s just that somewhere in the base of the spine, there is a flicker of anxiety: the uneasiness of weight being redistributed.

I put down my glass and finger the lump with fascination. It is about a centimetre in diameter and neatly spherical, with a shallow raised ridge. It feels like finding the shilling in the Christmas pudding.

‘Look, I’m sure . . .’

‘Mmmn? I can’t feel anything.’

R leans towards me on the sofa, touching my breast absent-mindedly, while he gazes back at the screen. ‘No, really I can’t feel anything.’

The Marriage of the Arnolfini, Jan Van Eyck, 1434. The Flemish merchant Giovanni di Nicolao Arnolfini stands with his wife in their intricately depicted bedchamber. Their surroundings are rich: ornate brass chandelier, fur-trimmed costumes, the splendid red fastness of the bed with its woollen bolsters and drapes. But affluence is not what strikes us about them. They are as stark and bare as saints. The natural light from the window touches them, he with his tapering hand upraised, she with her hand laid in his, palm up, as if giving herself without constraint or condition to their union. It is easy to see why scholars thought the painting might be a form of legal witness to a marriage. Their gazes are solemn, their gestures grave. Meantime, the little dog at their feet, a terrier, with its bright eye and tatty fur, suggests affectionate, domestic moments (some have seen it as an icon of lust, or fidelity), while the wooden pattens on the floor to their left tell of the street beyond, muddy and turbulent, full of trade and competition.

But in this room, now, there is stillness. What does the merchant mean by his upraised hand? What does the woman mean by her inclined head, plump with shadow, the tenderly gathered folds of green velvet at her belly? And what does the spectator mean, reflected in miniature in the convex mirror behind them? Is he a witness to the ceremony, as some have inferred?

This is northern light, the painter seems to tell us. Not so much fleeting, as scarcely emergent. Much of the room is already in shadow. And these two, blessed by it at the height of their union, when everything is full of promise ‘ from the pendulous red bolsters suspended from the bed, to her swollen belly; from his mysterious gesture of command, to her subtle half-screened smile ‘ are already in the act of vanishing.

Now, in an inversion of the painting, I take R’s hands, which I have always loved, which are not tapering like the merchant’s but have a masculine blunting at the tips, and are dusted with hair at the knuckles, and place them carefully at the site of the lump.

‘Oh yes.’ And in his voice I hear the mirror of my own curiosity. Not fear. Just a detached kind of wonder.

‘Maybe I should tell them tomorrow?’

‘You think?’ he says uncertainly.

Tomorrow we are due to report to the cancer genetics clinic of the Royal Marsden Hospital in London, where I will have a routine annual check for breast cancer. I have inherited M18T, a mutation on the BRCA1 gene, a gene known to be involved in the body’s suppression of tumours. We don’t yet know for certain whether M18T is harmful, or ‘deleterious’. Only a hundred or so of the many mutations that can crop up on the long and complex BRCA1 gene are critical to its function. But if M18T is one of them, then I have a very high risk of developing breast or ovarian cancer at a relatively young age. At present, the head of the cancer genetics clinic at the Marsden has described M18T as technically ‘of uncertain clinical significance’ . But it’s not looking good. There’s my own mother, who died of ovarian cancer at forty-two; her mother, who also died f ovarian cancer; and a cousin in my own generation who developed breast cancer at the same age.

You might have thought that all this would make me particularly careful in my breast examinations. But no. It doesn’t seem to work like that. If I think of my mother and her premature death, I become a little breathless. At forty-four, I already have the sense of living on borrowed time. But I had a mammogram eight months ago that pronounced me clear of cancer. And in general, the new knowledge that medicine has offered does not always tend to make me more careful. What it actually makes me, in respect of my own risk of contracting breast cancer, is running scared. And that is something different.

‘I think I should probably tell them tomorrow, shouldn’t I?’ I repeat.

‘No,’ says R, more decisively. ‘I really don’t think they’re for bothering with that. If you’ re worried about it, you should take it to the GP.’

Suddenly, I’m angry, more than angry. So furious that I can hardly get my words out.

‘Well, what are they for exactly? This so-called cancer genetics clinic. At the Royal Marsden Cancer Hospital. Which is supposed to help me not to get cancer. Which otherwise I am pretty certain to get. When my mother died of ovarian cancer at forty-two. When a cousin had breast cancer at the same age. When I have been told I have an eighty-five per cent chance of getting breast cancer myself, if you remember. What exactly are they for, R, if not for bothering?’

Poor R blinks in the sudden blaze, while the screen erupts with a roar in the background.

‘Well, tell them then,’ he says mildly. ‘If you think it’s that important.’

‘Thank you. Thank you so much. For taking my life so seriously.’

And I have completed the circle. It is he who does not care about my life, who prevaricates, who dandles this possibility of disaster before us and tosses it away like a trinket from the pram. I roll up my sleeves for a fight. I am energised, in good shape, my enemy before me. With hindsight, I see the pair of us with tenderness, like Miranda and Ferdinand in The Tempest, bent over a chessboard at the edge of the sea. We are playing at dread. Soon the storm will pick us up, whirl us about until we have lost sight of each other in the dark and our fingers cannot meet, tearing our proud puerility to shreds.